Provider Demographics
NPI:1871896753
Name:MARK W. STAGIS DDS, NATHAN E. VICK DDS DENTAL GROUP
Entity type:Organization
Organization Name:MARK W. STAGIS DDS, NATHAN E. VICK DDS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STAGIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-439-1245
Mailing Address - Street 1:6215 N FRESNO ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5267
Mailing Address - Country:US
Mailing Address - Phone:559-439-1245
Mailing Address - Fax:559-439-0312
Practice Address - Street 1:6215 N FRESNO ST
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5267
Practice Address - Country:US
Practice Address - Phone:559-439-1245
Practice Address - Fax:559-439-0312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA597351223G0001X
CA547931223G0001X
CA289871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty